Help & Hope for OCD

Compulsion neurosis. Obsessional neurosis. These are names given to OCD earlier in this
century. It was once thought to be a rare disease. Only 0.05% of the population was
estimated to be affected by OCD in1964. By 1977, those numbers grew to 0.32%. Still rare.
Today, major studies estimate a lifetime prevalence rate of 2.5% and a one year prevalence
of 1.5%-2.1%.

Have the numbers grown in the last three decades? Are we seeing an epidemic of OCD?

No, not at all. We are finding that OCD is not rare at all. There are no more people
afflicted with the disorder now than in 1964. The mistaken rarity of OCD is due to the
secrecy of people who have the disorder. Shame, guilt and self-blame keep us from exposing
our secret struggle with obsessive thoughts and compulsive rituals.

Blaming internal conflicts and external frustration for OCD, Sigmund Freud used
psychoanalysis to treat the disorder. The results of this treatment were not good, and OCD
continued to be known as a perplexing disorder to treat. Even Freud admitted being puzzled
by OCD. He promoted his psychological theories and they became widely used for many years.
But even Sigmund Freud looked toward a future when biology and chemical substances would
play an important role in psychiatric research and treatment.

That future has arrived. Todays techniques, such as positron emission tomography
(PET), single-photon emission computed tomography (SPECT) and magnetic resonance imaging
(MRI), have moved psychology from theories to research. Scientists can now look at
chemical reactions in the brain. They have found that OCD is likely caused by
abnormalities in specific parts of the brain, not unconscious conflicts, poor parenting or
dysfunctional families.

OCD appears to be linked to problems with a brain chemical called serotonin. Five
medications have been developed to help correct this chemical imbalance  Anafranil,
Prozac, Luvox, Paxil, and Zoloft. Most people can get reduction of OCD symptoms from at
least one of these medications. Others get relief from a combination of medications. Why
is this? Shouldnt one medication work for everyone afflicted with OCD? This tells us
that the serotonin imbalance is not the only problem behind OCD. Next month I will discuss
specific abnormalities of brain structure that affects OCD symptoms.

Until the 1960s, psychoanalysis was the therapy most used to treat OCD. While
medications were being developed to successfully treat OCD, therapy was changing too.
British psychologist Victor Meyer began using behavior therapy treat OCD in 1966. He
exposed hospitalized OCD patients with severe contamination fears and cleaning ritual to
feared objects and situations such as bathroom doorknobs and faucets. Meanwhile, he
severely restricted their showering and washing. He turned the water off, except to areas
used strictly for toileting!

Meyers innovative treatment worked! Out of fifteen, fourteen of his patients had
rapid reduction of their OCD symptoms. By the end of treatment, ten were symptom-free or
much improved, while five patients achieved moderate improvement. Since then, studies
around the world have shown improvement of OCD symptoms with behavior therapy.

Unlike psychoanalytic theory, which maintains that much of our behavior is out of our
control, behavioral psychology maintains that we can gain control over our behavior.
Studies have shown that behavior therapy can help correct the chemical imbalance in the
brain, similar to the way medication does.

In the 1980s researchers began recognizing the role of thoughts, beliefs and attitudes
in predicting human behavior. Consequently, cognitive therapy was developed as a
complement to behavior therapy. Cognitive therapy helps patients dispute faulty thought
patterns and irrational beliefs that result in abnormal behavior. Together, this is often
referred to as cognitive-behavior therapy. You will see, even in my writing, the terms
behavior therapy and cognitive-behavior therapy used almost interchangeably.

The cornerstone of cognitive-behavior therapy for OCD is what we call exposure and
ritual prevention (ERP). It is also called exposure and response prevention. The patient
is exposed to the obsessive thoughts and fears. Then he prevents himself from responding
in the usual manner  with compulsive behaviors or thoughts.

Many people can use self-help books to find relief from obsessive-compulsive thoughts.
Resources specifically for people with OCD are available through the Obsessive Compulsive
Foundation at http://www.ocfoundation.org
Others will need professional help. I strongly advise anyone who thinks they may
have OCD to consult a psychiatrist for a complete mental health checkup. Accurate
diagnosis is the first and most important step toward recovery.

Treatment of OCD

The most effective treatment for OCD is a combination of cognitive-behavior therapy
(CBT) and medications. Studies have shown that a combination of CBT and medication
produces better results than either treatment used alone. Although more difficult and time
consuming, CBT has demonstrated more lasting results. Relapse is frequent when medication
is withdrawn.

Medication Therapy

The medications most commonly used in treating
OCD are antidepressants. The medications most often used to treat OCD treatment are
fluvoxamine (Luvox), fluoxetine (Prozac), sertaline (Zoloft), paroxetine (Paxil)
clomipramine (Anafranil), citalopram (Celexa), and escitalopram (Lexapro).

These medications are not chemically related, but they all work by inhibiting the
reuptake of serotonin.

Serotonin is one of the neurotransmitter chemicals that nerve cells in the brain use to
communicate with each other. These neurotransmitters are active when they are present in
the synaptic cleft between nerve cells. Transmission is ended when the chemicals are taken
back up into the transmitting cell. The SRIs and SRRIs slow the reuptake of serotonin,
making it more available to the receiving cell and prolonging its effect on the brain.

Increasing serotonin appears to produce changes in receptors in some of the membranes
of the nerves. It is believed that these receptors may be abnormal in patients with OCD.
SSRIs may also affect other brain chemicals. Sometimes a patient will not respond to the
first medication and will have to try two or more of the SSRI's before finding one that
works for him.

Cognitive-Behavior Therapy

Completion of a course of CBT appears to work as well as
medication for the treatment of OCD. Research is finding that, over time, CBT can change a
person's brain chemistry. People with OCD tend to stay in long-term remission, requiring
only occasional refresher sessions.

The complication is that CBT requires great motivation and cooperation on the person's
part. When used together, medication and CBT complement each other. Medication alters the
serotonin available, while CBT helps modify behavior by teaching the person how to resist
compulsions and obsessions.

Exposure and ritual prevention (ERP) is the cornerstone of cognitive-behavioral
treatment for OCD. Cognitive-behavior therapy utilizes ERP and techniques that will help
you change the faulty beliefs people with OCD often maintain.

Exposure and ritual prevention (also called exposure and response prevention) are the
principal behavioral techniques for treating OCD. The purpose of exposure is to decrease
the anxiety and discomfort associated with obsessions through habituation. This may be
done by desensitization with brief imaginal exposure or prolonged exposure to the
real-life ritual-evoking stimuli. For example, the person may be exposed to garbage or
other contaminated objects without relieving the anxiety by washing his hands. As the
person realizes that the feared consequences will not occur, the anxiety decreases. This
is called habituation.

The purpose of ritual prevention is to decrease the frequency of rituals. The person
with OCD is faced with feared stimuli without practicing rituals, such as hand washing or
excessive checking. At first, the person may be allowed to delay performing a ritual,
working gradually toward resisting the compulsion.

A graded hierarchy of anxiety producing activities and situations is constructed. The
Yale-Brown Obsessive Compulsive Scale can help with identification. Exposure often begins
with the least anxiety provoking situation. Some therapists focus on situations
that produce moderate anxiety first to achieve more rapid progress. Which one is
employed will depend on the therapist's choice and the person's ability or willingness to
tolerate anxiety. One or two obsessions and rituals are worked with at a time to avoid
overwhelming the person.

The person with OCD is assigned homework exercises. He or she may need assistance with
these assignments from family members or the therapist's home visits. Participant modeling
may be incorporated in exposure and ritual prevention. The person is asked to copy the
therapist. I observe my family and friends to help me determine "normal"
behavior. When I am not sure if my behavior is appropriate, I ask one of my support
people.

Family members should be asked to participate in the therapy. Role-playing under the
supervision of the therapist can help them understand homework assignments. Keeping a
diary can help by serving as a reminder of progress. It also helps the therapist identify
areas of resistance.

In some cases, people experience OCD symptoms only in particular situations. Exposure
and ritual prevention may need to be carried out in special settings. Home visits or field
trips may be required by the therapist.

For best results, the therapist needs to be well trained in CBT, the OCD person must be
highly motivated and faithful in fulfilling homework assignments and the person's family
needs to be cooperative. Often, finding a therapist experienced in the treatment of OCD is
difficult. The Obsessive Compulsive
Foundation can help you find a therapist interested in OCD treatment. But CBT can also
be done on your own. The OCD Workbook
uses the Self-Directed Program to guide readers through individualized cognitive-behavior
therapy.

Support Groups

Support groups help people with OCD realize that their symptoms
are not unique. The family should also be involved in a support group, if one is
available. This is especially important for parents of children and adolescents. Support
groups can also help with education about the disorder.

GOAL (Giving Obsessive-compulsives Another Lifestyle) is a support group in
Philadelphia. Founded in 1981, it is probably the oldest OCD support group in the country.
Emphasis is on choosing behavioral goals to work on between meetings. Dr. Jonathan
Grayson, Ph.D., one of GOAL's founders, advises having a professional experienced with OCD
assist the group. This person would help keep the meeting on track, give individual
assistance when needed and answer questions.

GOAL meetings are divided into three parts: discussion of a particular topic, chosen by
the group leaders prior to the meeting; goal planning; and informal socializing. GOAL
groups are discussed in the audio cassette, "Making and Maintaining Goals-G.O.A.L.
Support Groups," by Jonathan Grayson, Ph.D. and Gayle Frankel. It is also available
through the OC Foundation. I have posted an OCF Newsletter article about GOAL groups,
written by Dr. Grayson. Click here to visit it.

Obsessive Compulsive Anonymous (OCA) was founded in 1988 by Roy C. OCA uses principles
similar to other12-step programs. Roy C. describes the program in the book, Obsessive
Compulsive Anonymous-Recovering from Obsessive Compulsive Disorder. It is available
through the OC Foundation. OCA has a website at http://members.aol.com/west24th/index.html

Family Support

Sometimes family members or friends recognize signs of OCD before
the person with the disorder does, or the person may refuse to seek help. If you know
someone with symptoms of OCD, educate yourself about the disorder, then bring educational
materials into the home. Share the information in a gradual and nonthreatening way. My
book, Loving Someone with OCD, is a helpful resource.

Do not assist the person with their obsessive-compulsive behaviors. It is best to
withdraw help with rituals gradually. Tell your loved ones you will help them resist the
compulsions and you will help them obtain help, but you will no longer be a part of their
compulsions. Examples would be participating in washing rituals, checking appliances for
the person, answering the same question repeatedly and offering frequent reassurance.
Offer to help the person find a mental health professional that is experienced in the
treatment of OCD.

Once the person with OCD begins treatment, family members play an important part in
recovery. People often need a support person at home to assist them with the exposure
tasks and homework assignments. Before taking on the role of support person, learn what
will be expected of you. This will be a long-term project, often requiring regularly
scheduled time to help with homework assignments.

Family members and friends who are not taking on the role of support person can also
help the OCD person. These are steps the family can take to encourage recovery:

Reduce stress, especially during early treatment. Keep the family routine as normal as
possible.

Communicate with the health care team and with each other. Keep communication simple and
clear.

Be supportive and encouraging. Recognize even small signs of success. Avoid comparisons
with others who have OCD or with family members without the disorder. The person with OCD
may already have a low self image.

Don't place blame for OCD on anyone. OCD is no one's fault. Try not to react critically
to OCD behaviors and thoughts.

Encourage compliance with medication and CBT. Due to side effects, the person may need
reminders to take his medication. I put my medication in a weekly reminder box to avoid
missed or extra doses.

Help the person with OCD set reasonable goals. Setting expectations too high sets us up
for failure.

Beware of reassurance seeking. People with OCD often try to avoid anxiety by seeking
reassurance from others. This becomes an avoidance behavior in the same way that a ritual
is an attempt to avoid anxiety. There are times when reassurance is allowed, such as
reassuring the person that behavior therapy is effective in treating OCD. My family
offered reassurance once when I was obsessing about something. When I repeated a question
or rephrased it, they tried not to answer it again. A good response would be, "The
doctor has instructed us not to reassure you," delivered in a monotone voice.

Practice responses you will give to reassurance seeking with the person who has OCD.

Be familiar with signs of relapse and encourage the person with OCD to seek professional
help when these signs are first noted.

Obsessive-compulsive disorder was once thought to be almost untreatable. Over the last
couple decades, two treatments have been proven effective in the treatment of OCD 
medication and cognitive-behavior therapy (CBT). Together they are powerful tools in the
struggle against OCD.

Cognitive-behavior therapy is actually the combining of two types of therapy. Behavior
therapy has been used to treat OCD for over twenty years and numerous studies prove its
effectiveness. It uses methods of changing behavior. Cognitive therapy has recently joined
forces with behavior therapy. It involves strategies for helping to change the faulty
beliefs prevalent in OCD.

The type of behavior therapy used to treat OCD is called exposure and ritual prevention
(ERP) It is also called exposure and response prevention. Patients are taught to expose
themselves to that which they fear. As the anxiety rises, they then work to resist the
usual ritual that reduces the anxiety. For example, a person with fear of contamination
would expose himself to what he considers unclean or "contaminated," then resist
hand washing or showering.

Exposure and ritual prevention is best done in stages  baby steps. My biggest
problem was checking. When my OCD was at its worst I checked everything, often several
times. Leaving the house involved checking the lights, the stove, coffee pot, computer and
any other appliances. Then checking that the back door was locked and all the cats were in
the house. If I was interrupted, Id have to start over. I started at the back of the
house and worked my way to the front door. Finally, I could go out the door. Then I had to
lock the door, check it, lock it again, check it. When I got to the car, I was often
struck with a fearful thought that made me go back and check again:

"Maybe I accidentally turned the stove on when I was checking it."

"Did I lock the door?"

"Maybe I unlocked the door instead of locking it."

"Did I let the cat out?"

When I determined to attack this problem with OCD, I made a plan. The first step was
easy. Sounded easy anyway, but it wasnt easy to me. I changed the order and method
of checking things each time I left the house. Instead of starting at the back of the
house, I started with the kitchen. When I checked the stove, I didnt touch the knobs
as I was accustomed to doing.

As I gained confidence and the initial anxiety was reduced, I got braver. I left the
house for 15 minutes without checking anything. Finally I was able to leave the house for
several hours or all day after just checking the appliances only once. I can now lock the
door and walk calmly to the car. Usually! Sometimes, very rarely now, the fear comes back.
"I was in such a hurry, did I lock the door? Maybe I forgot." I can usually
continue on without going back to check. But I still feel compelled to go back and check
sometimes. I feel like I cant resist. And you know what? When I go back to check,
the door is always locked!

When I learned about exposure and response prevention (ERP), I made goals for myself. I
enlisted my husband Jim and my son James to serve as support persons and asked them to
help me with my self-imposed rules. Rule #1 was "REASSURANCE ONE TIME ONLY!"
When I asked for reassurance, they reassured me once. Almost always, I rephrased the
question and asked again. I instructed them to remind me, "We are not allowed to
answer that question again."

What kind of reassurance? I asked questions such as:

"Are you sure I locked the door when we left the house?"
"What if I didnt cover my mouth when I coughed and there was a child near
by?"
"Do you think I let the cat out on the way out the door?"
"What if I didnt sign the check I just mailed?"
"I think this shirt touched the floor, should I wash it over?"
"I felt a bump, did I just hit someone with the car?"

Often I argued and pleaded. Sometimes they relented and gave me the reassurance. I knew
and they knew this was not the best thing for me. Success  and improvement of my OCD
 came only when they stood strong, with me, against the enemy, OCD.

I had some problems with hand washing and laundry. I wasnt afraid of harming
myself, but of harming others. If I didnt wash my hands before touching the clean
laundry, I might pass a germ on to someone else. Laundry that touched the floor became
"contaminated." I made "laundry rules." No extra handwashing before
touching the laundry. Clothes that touched the floor must not be re-washed.

I cheated a lot at first. But the more I obeyed my rules and resisted the urge to do
the laundry rituals, the stronger I became. Today, I can do laundry without extra
handwashing. Even underwear can touch the floor!

Checking was my worst problem. I made "checking rules." I allowed myself to
check the door, stove and coffee pot before leaving the house or going to bed, ONCE. If I
was interrupted, I was not allowed to go back and check. Once I left the house and got in
the car, I could not go back and check anything again.

My son was helpful with this one. Often, his gentle, "Mom, you cant go
back," was all I needed to give me strength not to jump out of the car and go check.

For a while, I had the "hit and run" problem too. I would be driving along
and suddenly be struck with the fear I had hit someone. Sometimes I went back several
times to check the road. My son would reassure me with, "No Mom, everything is OK,
you didnt hit anyone."

When I learned more about ERP, I realized the reassurance my son gave me was only
making my problem worse. It was hard, but I did it  I told my son not to give me
reassurance. He was to say, "Mom, I cant reassure you." I got angry with
him, I cried and pleaded with him. Sometimes he gave in. Then little by little, we both
became stronger and resisted.

I knew I was getting better when my son could say, "Yeah, Mom, you hit three kids
back there," and I didnt get angry with him. I had other car rules too. No
going back to check for dead bodies. Only "normal" looking in the rear view
mirror. (I knew when I was looking in the mirror for dead bodies or fallen bicycles. If
you have a problem with driving, you know when you are checking too.) No looking back at
groups of kids on the side of the street.

ERP is hard work, but it is worth the effort to break free from the chains of OCD.

Are you bound by too many
rules? Could the rules be connected to your OCD? Do you have trouble deciding if your
rules are reasonable rules that any prudent person would have?

I am very rule oriented. I
have a few rules for how other people should behave, but most of my rules govern my behavior. Rules "protect" me from
danger, discomfort and embarrassment. I tend to think that they also keep me from later
obsessing  that if I follow specific rules, I wont obsess later. But the rules
get in the way when I can't remember if I did a step in the checking process. For example,
I could reduce obsessing about locking the door by going through a series of steps
and mindfully locking it.

But there comes a time when I
just automatically lock the door and go to the car. What if I didn't lock it? Do I go back
and check? Rules are fine, but Ive learned that when you do something every day it
becomes familiar, almost automatic. We get into a habit
of locking the door when we leave the house. When my OCD was moderate to severe, I must
have gone back to check the door at least a hundred times over the years. In fact, I
checked the door so much I wore out the lock and we had to replace it!

Rules are quite important,
living by them defines our characters.And
doing things mindfully is helpful for people with OCD. But we need to keep in mind that
those same rules that we use to protect ourselves from obsessing later very well may
backfire. When we forget one step, we give added importance to the rules. If I didnt follow the rules, then I may not
have locked the door. For me, that thought would grow and grow until I told myself I just know I didnt lock the door. So back I
would go to check the door. When OCD gets the best of me, I still go back and check on
occasion. And of all the times Ive gone back to check, the door was never left
unlocked.

My contamination fears taught
me another lesson about rules and OCD. I have had hand washing rules in the kitchen. Wash
your hands after handling raw meat or eggs. But what about milk? Or what about mayonnaise?
When I was making something for others, the rules were even stricter. I once gave up on
making a relish plate for church after the second try and ended up putting it all in the
refrigerator for my family to eat. I kept thinking I had touched an olive, then a pickle.
We stopped at the store to buy something packaged for the potluck.

I had a rule about not
touching other people's food. So if I did, it was contaminated. Most people do have rules
for good hygiene in the kitchen. But if they break a rule, they can logically decide if it
was a major rule, like not frosting a cake and taking it to a church function after the
cat took a bite out of it. I did that one time in my pre-OCD years! Or was the rule a
minor rule, like not touching a pickle? For many people with OCD, there are no minor
rules.

I still think it is fine to
have kitchen rules. But be prepared for the time when you break the rules. I think a good
prevention of the inevitable obsessions when rules are broken is to plan ahead. Write out
your rules, then sit down with a prudent person, a support person, and go over your rules.
Are they legitimate hygiene rules that most prudent people would follow? Or are they
excessive rules? Cross out the rules your support person says are excessive. Now, you have
a new list of rules, but youre not done yet. Ask your support person which of the
rules can be broken. What if I dont follow these rules? Which ones are major rules
that should never be broken and which ones are minor rules that wont hurt to be
broken occasionally? Make a new list with major rules in one column and minor rules in
another column.

When a minor rule is broken,
you can accept it as just a slip up and carry on. No need to trash the dinner. When a
major rule is broken, you can take the proper steps to correct the situation. If this
causes way too much anxiety, you could move some of the major rules into the minor rules
column. When anxiety reduces, you could move them back into the minor rules column. I
guess this is kind of an exposure. Getting rid of unnecessary rules will cause some
anxiety. Resisting following them is the ritual prevention.

So, this is an exposure and
ritual prevention exercise (ERP) ala Cherry. Im
not a therapist, doctor or counselor, but someone with a few ideas who has experienced
OCD. With a little thought you can get creative and come up with your own tailor-made ERP
exercises.

Someone recently wrote to me
about medication. Isnt medication crutch? Would God approve? Wouldnt He want
us to conquer the fears and doubts of OCD without medication? Isnt taking medication
an admission of failure?

Fear of taking medication is
very common in people with OCD. We tend to want to handle it ourselves. And for a
Christian  or someone of another religion  that fear is even worse. I had
reservations about taking medication too. But when you really think about it, it doesn't
make sense. OCD is a neurobiological disorder. A problem with the brain. And God made us.
He also allowed all the technology and research to be done. I think He works in many ways.
And one is by providing people to do the research and develop medications to help make
illnesses more tolerable.

If you are struggling with the
medication question, another way to look at it is this: medication can help you get well
enough to more fully work on cognitive behavior therapy. When the OCD is improved, you
could consult your doctor. If you both agree you are ready to give it a try, you could ask
your doctor to help you reduce and quit the medication. We don't have to decide today, to
be on medication for the rest of your life. We only need to decide if we should be on
medication now. I would set a time period to be on medication and work on therapy. Then
ask your doctor and, with his help, you could try to reduce or quit it. If it doesn't work
out, you can start medication again. If one medication doesn't work well, you can try a
different medication. Think of this as temporary decisions you are making for a few months
at a time.

Exposure and ritual prevention
is hard work. It means exposing yourself to what you greatly fear, then resisting the
usual ritual or response. In my case, checking was my worst ritual. If I didnt check
certain things before leaving the house, something bad might happen. Someone could break
in and steal everything if the door wasnt locked. The house could burn down if the
stove was left on. The coffee pot could blow up if it was left on.

I didnt fear the harm
and hardship it would bring to me, but the harm it could bring to my family. I even
obsessed that if the car was left unlocked a child could open the car and take one of my
pills I kept in the glove box, even though it was in a childproof container. Or a child
could start the car and be injured. If I didnt put the brake on in the driveway,
which was on a slight incline, it could spontaneously roll down and hit a child innocently
walking by.

Full exposure to these fears
would mean leaving the house without doing my usual checking. I didnt have formal
cognitive behavior therapy. I applied the principles I learned about in books. Leave the
house without checking? No way! That seemed much too difficult. Even visual checking,
without touching the knobs of the stove was out of the question. But I felt I could handle
a gradual approach.

I checked the stove, coffee
pot, etc. once, in a "normal" sort of way (looking at the stove knobs and not
touching, for example) then left the house for a few minutes. Then I would check and leave
for longer periods of time. Then I left the house for a few minutes without checking and
increased the time period as before. For me, if I was leaving for a short while, the
obsessions and the compulsions to check were weaker, so this helped.

Another thing I did at first
was this  I did my checking in a different order. Instead of checking the toilets,
lights, computer, back door, appliances, stove, etc. in my usual order, back of the house
to front, I changed the order and checked things in a random order. The checking didn't
feel right so it was an exposure, but a weaker one and more tolerable.

But I didn't stop, I continued
to make the exposure stronger and stronger until I was only checking things once. Now I
check to make sure the lights and are off, then leave the house. For me, checking
compulsions were kind of difficult to stop because checking needs to be done in normal
life. Like eating  we need to do it, but not excessively.

My approach might sound wimpy
to a lot of therapists, but then I didn't have formal behavior therapy. I learned from
books and used the principles to reduce my OCD symptoms. Because no one was pushing me, I
did it at my own speed. Im sure it took longer than if I had pushed myself more, but
in my opinion, wimpy like me is better than no exposure at all. Dont avoid exposure
and ritual prevention because you think it would be too hard. Do what you can, but do
something. If you choose a more gradual approach, keep working at it. It can be tempting
to stop when the rituals no longer seem to interfere with your life. I did this, then
realized they really did interfere with my life. Some rituals came back full force because
I eased up on exposure and ritual prevention. However you do it, keep working at it. For
me, it is a lifetime process.